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Review Annals of Internal Medicine

Narrative Review: Hyperkyphosis in Older Persons


Deborah M. Kado, MD, MS; Katherine Prenovost, PhD; and Carolyn Crandall, MD, MS

Hyperkyphosis is a widely recognized yet largely ignored condition. be independently associated with an increased risk for adverse
Although there are no uniform diagnostic criteria for hyperkyphosis, health outcomes, including impaired pulmonary function, decreased
current studies estimate its prevalence among older adults at 20% physical function capabilities, and future fractures. With the grow-
to 40%. The causes and consequences of hyperkyphosis are not ing older population, we now need research that leads to a deeper
well understood. Some physicians think that fractures cause hy- understanding of the causes, consequences, and treatment of this
perkyphosis and that management strategies should focus solely on common condition.
diagnosis and treatment for osteoporosis. Recent studies, however,
demonstrate that many older adults who are most affected by Ann Intern Med. 2007;147:330-338. www.annals.org
hyperkyphosis do not have vertebral fractures. Hyperkyphosis may For author affiliations, see end of text.

(n 408) or warranting detailed consideration of the orig-


W ith aging, the sagittal convexity of the normal tho-
racic spine, known as kyphosis, tends to progress (1).
Hyperkyphosis, an excess of this process, is often called the
inal article (n 210). We also excluded reports that were
not in English (n 1365) and those that addressed the
dowagers hump. Although not precisely known, the preva- following: 1) primary surgical interventions in children or
lence and incidence of hyperkyphosis in older persons is young adults (n 1386); 2) trauma-induced hyperkypho-
probably between 20% and 40% (2 4). The causes and sis, such as thoracolumbar burst fractures (n 107); 3)
consequences of hyperkyphosis are not well understood. hyperkyphosis caused by chronic diseases, such as Pott dis-
Most clinicians and laypersons assume that hyperkyphosis ease (n 558); and 4) other conditions, such as scoliosis
results from underlying vertebral fractures; however, verte- or kyphoscoliosis (n 1108). As we reviewed the remain-
bral fractures are present in only 36% to 37% of the most ing publications, we paid attention to study design and
severe kyphosis cases (5, 6). Furthermore, hyperkyphosis is sample size, characteristics of the participants, and whether
not simply an undesirable cosmetic consequence of aging. studies addressed factors other than kyphosis that could
It may be associated with several adverse health outcomes, have influenced outcomes.
such as poor pulmonary and physical function.
Our narrative review presents evidence that hyper-
kyphosis cannot be fully explained by osteoporosis and that HOW DOES ONE MEASURE KYPHOSIS?
it is a distinct geriatric syndrome deserving of more atten- The normal spine has 3 curves in the sagittal plane:
tion. With increased clinical awareness informed by con- cervical lordosis (anteriorly convex), thoracic kyphosis (an-
tinued research, physicians can begin to help prevent and teriorly concave), and lumbar lordosis. Kyphosis can be
treat hyperkyphosis and may avoid or lessen attendant ad- measured from radiographs or with such devices as the
verse health consequences. kyphometer (7), goniometer (8), inclinometer (9), and
flexible ruler (1) (Figure 1). Developed first to assess sco-
METHODS liosis angles on spinal radiographs, the Cobb angle was
modified to measure kyphosis. Considered the current gold
We searched MEDLINE and PubMed (OLDMED-
standard measurement, it is calculated by drawing a line at
LINE for pre-1966) for studies from 1950 through 28
the upper border of the vertebral body, marking the begin-
November 2006 by using the following Medical Subject
ning of the thoracic curve (commonly T4), and at the
Heading terms and keywords: kyphosis, hyperkyphosis, and
inferior border of the vertebral body, representing the in-
kyphotic posture. We reviewed all citations and available
terface between the thoracic and lumbar curves (commonly
abstracts (4734 for kyphosis, 77 for hyperkyphosis, and 87 for
T12). Perpendicular lines are drawn from these 2 lines, and
kyphotic posture). We classified 618 abstracts as not relevant
the angle of their intersection is the Cobb angle (Figure 2).
Other clinical assessments of kyphosis include qualitative
visual measurements (3, 4) and measurement of either the
See also: distance from the occiput to wall (10) or the number of
1.7-cm blocks between the head and examination table
Print
while the patient is lying flat with the neck in a neutral
Key Summary Points . . . . . . . . . . . . . . . . . . . . . . . 331
position (2).
Web-Only Research has not fully disentangled the differences be-
CME quiz tween clinical and radiologic kyphosis measures. In a study
Conversion of graphics into slides of 26 postmenopausal women (7), independent observers
Audio summary measured kyphosis similarly when they used Debrunner
kyphometer, flexicurve-derived kyphosis angle, and radio-
330 2007 American College of Physicians
Hyperkyphosis in Older Persons Review

graphic Cobb angle measurements. Intraclass correlation


estimates for the measures ranged from 0.87 to 0.92 (7). Key Summary Points
Traditionally, the Cobb angle is measured from stand- Hyperkyphosis is a common geriatric condition that affects
ing lateral spine films. However, in elderly persons, spinal as many as 20% to 40% of older adults.
radiography is usually performed with the patient in the
supine position for comfort. Because gravitys effect on Hyperkyphosis affects both men and womenthe lay
posture is lost while supine, the kyphosis angle measured in term dowagers hump is a misnomer.
the lying position may underestimate kyphosis. In a study
that compared the standing Debrunner kyphometer angle Vertebral fractures are present in only about one third of
with a supine radiographic Cobb angle measurement in the older adults with the worst degrees of thoracic curva-
120 women age 55 to 80 years (11), the mean difference ture.
between the 2 measures was only 4. The Debrunner
Hyperkyphosis may be associated with multiple adverse
method overestimated the Cobb angle slightly, and the
health outcomes, including impaired pulmonary and physi-
intraclass correlation coefficient for the measures was 0.68
cal function, fractures, and possibly increased risk for
(11).
death.

HOW DOES ONE DEFINE HYPERKYPHOSIS? Research about the cause, consequences, and treatment
for hyperkyphosis is urgently needed because available
In younger populations, normal kyphosis angles range
evidence is scant and the prevalence of the condition will
between 20 and 40 (12). In older adults, the mean ky-
probably increase as the population ages.
phosis angle is about 48 to 50 in women (6, 1315) and
about 44 in men (6). We know that the angle increases
with age (1, 6, 12, 16 26), but we do not have uniformly
accepted thresholds for defining either hyperkyphosis or
index increased with age and explained 42% of the varia-
normal thoracic spine changes associated with aging.
tion in kyphosis in men and 48% in women (29). Other
One longitudinal study of 100 healthy men and
studies reported correlations between wedge angles and ky-
women age 50 years or older (mean age, 62 years) reported
phosis ranging from 0.45 to 0.78 (14, 18, 19). In studies
a mean thoracic angle increase of 3 per decade (27). In a
that compared kyphosis between people with and without
longitudinal study of 10 women (mean age, 77 years) fol-
vertebral fractures, those with vertebral fractures had worse
lowed for 3 years after a vertebral fracture (24), the mean
kyphosis (6, 15, 32).
angle increase was 5.6. Cross-sectional studies reported
that the oldest age groups had the most pronounced in- Postural Changes
creases in kyphosis (12, 21, 23). For example, 1 study of Postural changes affecting the cervical, lumbar, and
men and women reported mean thoracic kyphosis angles of sacral spinal areas and postural flexibility may influence
26 in persons in their 20s, 53 in those 60 to 74 years of thoracic curvature. For example, investigators have found
age, and 66 in those older than 75 years of age (23). An weak but statistically significant correlations between Cobb
ongoing large prospective cohort study will soon provide angle thoracic kyphosis and cervical lordosis in men (r
important longitudinal data on rates of progression in 0.27; P 0.03) and women (r 0.33; P 0.009) (23).
older women (28). In 300 volunteers age 20 to 70 years, researchers reported a
correlation of 0.35 between radiographic measures of
thoracic kyphosis and maximum lumbar lordosis (P
POTENTIAL CAUSES OF HYPERKYPHOSIS 0.001) (33). In a study involving 51 women (34), those age
Vertebral fractures do not explain all cases of hyper- 66 to 88 years had greater flexicurve kyphosis than those
kyphosis (29). Only 36% to 37% of older persons with the age 21 to 51 years (mean kyphotic index, 11.1 [SD, 3.9]
worst degrees of kyphosis have underlying vertebral frac- vs. 7.2 [SD, 2.2] during erect stance). The older women
tures (5, 6). Other postulated causes of hyperkyphosis in- were less able to actively correct their posture from a re-
clude postural changes, degenerative disk disease, muscular laxed to an erect position (34).
weakness, ligamentous degeneration, and genetic predispo- Degenerative Disk Disease
sition (Figure 3). A few cross-sectional studies report an association be-
Vertebral Fractures: The Most Cited Cause of tween degenerative disk disease and kyphosis (6, 19, 35).
Hyperkyphosis In a study of 100 healthy women age 39 to 91 years (19),
In 1963, 2 publications noted an association between investigators found a statistically significant correlation be-
vertebral body wedging and kyphosis (30, 31). In the tween anterior disk height and kyphosis angle (r 0.34;
1970s, Milne and Lauder (1) developed the flexicurve mea- P 0.001). Using measurements of lateral spine radio-
surement of kyphosis and quantified the vertebral wedging graphs and mid-sagittal computed tomography films of 93
index from lateral chest radiographs. The wedge deformity ex vivo spines from men and women age 18 to 94 years,
www.annals.org 4 September 2007 Annals of Internal Medicine Volume 147 Number 5 331
Review Hyperkyphosis in Older Persons

Intervertebral Ligaments
Figure 1. The flexicurve: a noninvasive measurement of
Intervertebral ligaments provide stability to the spine
thoracic kyphosis.
and, with aging, are susceptible to loss of elastic tissue,
calcification, and ossification (43). In theory, any of these
changes might predispose an aging individual to hyper-
kyphosis. Indirect evidence that tight ligaments may con-
tribute to hyperkyphosis comes from a study of 11 cadav-
ers, in which segmental transections of the anterior
longitudinal ligament from T3 to T7 resulted in a 16
Cobb angle reduction (44).
Genetic or Metabolic Basis of Hyperkyphosis
Early-onset hyperkyphosis occurs in inherited genetic
conditions, including osteogenesis imperfecta, the Ehlers
Danlos syndrome, the Marfan syndrome, cystic fibrosis,
and Scheuermann disease. Scheuermann disease, the most
frequent cause of juvenile hyperkyphosis, is characterized
by a thoracic Cobb angle of 45 or greater and/or lumbar
kyphosis with associated vertebral wedging, end-plate irreg-
ularity, and disk space narrowing (45). The disease is prob-
ably inherited (46 49). However, with an estimated pop-
Reproduced from Lundon and colleagues (7) with permission of Spine. ulation prevalence of 8.3% (50), it cannot account for the
large prevalence of age-associated hyperkyphosis. Incom-
plete penetrance of certain genotypes may lead to milder
researchers reported a correlation of 0.52 (P 0.001) age-associated hyperkyphosis. In recent studies, older per-
between anterior disk wedging and Cobb angle (35). In a
third study of 1407 older men and women (6), with each
5-increase in Cobb angle, participants had a 36% (95% Figure 2. The Cobb angle of thoracic kyphosis, calculated
CI, 1.26 to 1.48) increased odds of having degenerative from a lateral radiograph.
disk disease. These cross-sectional studies did not establish
whether degenerative disk disease contributed to or was a
consequence of hyperkyphosis.
Muscle Weakness
With 2 exceptions (36, 37), most studies report an
inverse correlation between muscle strength and hyper-
kyphosis (8, 38 42). Although not a direct measure of
spinal muscle strength, grip strength measured in 151 men
and women age 65 to 85 years correlated with worse ky-
phosis measured from a lateral photograph (r 0.25;
P 0.005) (38). Similar findings of upper-extremity
strength and flexicurve-measured kyphosis include a corre-
lation of 0.32 in 47 women volunteers age 50 to 60 years
(P 0.05) (39).
Three studies reported a statistically significant associ-
ation between back-extensor strength and hyperkyphosis in
postmenopausal women. Two of these studies found cor-
relations ranging from 0.30 to 0.35 (40, 41). The third
study found that, among 25 women, those with hyper-
kyphosis (Cobb angle, 50 to 55) had weaker back-exten-
sor muscles (250 N vs. 150 N; P 0.05) than control
patients (Cobb angle 35). No adjustments were made
for apparent differences between the groups in age, body
size, or physical activity (42). In a study of 189 women age
50 to 80 years, those with weak back-extensor muscles
were more likely to have greater kyphosis (58 vs. 51 by
goniometer; P 0.01) (8). Reproduced from Kado and colleagues (11) with permission of Spine.
332 4 September 2007 Annals of Internal Medicine Volume 147 Number 5 www.annals.org
Hyperkyphosis in Older Persons Review

sons who reported a family history of dowagers hump vertebral fractures (P 0.02) but not compared with con-
were statistically significantly more likely to have greater trol patients. No adjustments were made for possible con-
kyphosis, independent of a family history of osteoporosis, founding (67). In 231 community-dwelling volunteers age
bone mineral density, or vertebral fractures (5153). 59 to 89 years, after adjustment for age, sex, body mass
Hyperkyphosis may be an end result of genetic lesions index, moderate to severe scoliosis, heart rate response to
involving genes important for DNA repair and delaying exercise, arthritis, and vertigo, those with hyperkyphosis
senescence. Several mouse knockout models that develop (assessed qualitatively and as the occiput-to-wall distance)
early senescence have pronounced hyperkyphosis (54 59). had reduced gait speed (P 0.015) and increased stair-
Whereas some researchers postulate that hyperkyphosis re- climbing time (P 0.001) (3).
sults from poor posture, results from the mouse studies In a Japanese community sample (n 237), persons
suggest that gravitational forces may not be an important 80 years of age or older with qualitatively assessed thoracic
cause because, unlike humans who stand erect, mice spend hyperkyphosis demonstrated slower gait speed (0.53 m/s
their lives in a prone position. vs. 0.59 m/s; P 0.05), a slower timed get-up-and-go test
result (14.9 seconds vs. 12.5 seconds; P 0.01), and less
functional reach (18.4 cm vs. 23.5 cm; P 0.001) than
ADVERSE HEALTH CONSEQUENCES OF HYPERKYPHOSIS did those classified as having normal posture. No adjust-
Impaired Pulmonary Function ments were made for possible confounding by age and
In a case series of 74 women referred for osteoporosis comorbid conditions (68). Of 1578 older U.S. persons,
evaluation, increased Cobb angle was associated with de- participants with hyperkyphosis defined by blocks had
creased FVC (R2 0.14; P 0.001) (60). Three other worse grip strength and more difficulty rising from a chair
small cross-sectional studies reported statistically significant (odds ratios, 1.5 to 3.7) with increasing kyphosis severity
negative correlations between hyperkyphosis and vital ca- compared with those with normal kyphosis. These findings
pacity and/or FEV1, with values ranging between 0.38 seemed to be independent of age, bone mineral density,
for vital capacity to 0.73 for FEV1 (61 63). In 323 older and self-reported vertebral fractures (69).
community-dwelling persons, those with qualitatively as- Increased Falls
sessed hyperkyphosis had restrictive ventilatory dysfunc-
Some postulate that hyperkyphosis fundamentally al-
tion, even after adjustment for age, sex, and body mass
ters balance and predisposes persons to falls (42, 70, 71).
index (adjusted prevalence odds ratio, 2.3 [CI, 1.1 to
Some studies challenge this assumption. Among 22 women
4.80]; P 0.02). After adjustment for age, sex, smoking,
with osteoporosis diagnosis, there was no association be-
and history of chronic bronchitis or asthma, persons
tween Cobb angle kyphosis and balance measures (72).
with hyperkyphosis were also more likely to have ob-
Similarly, in 151 older men and women, there was no
structive ventilatory patterns (adjusted prevalence odds
association between kyphosis and postural sway (38). Stud-
ratio, 3.3 [CI, 1.7 to 6.5]; P 0.001) and self-reported
ies that have investigated hyperkyphosis and fall risk report
dyspnea (adjusted prevalence odds ratio, 2.5 [CI, 1.1 to
conflicting results (9, 70, 73, 74). In the largest study (n
5.8]) (64).
1883), block-measured hyperkyphosis was statistically sig-
nificantly associated with self-reported injurious falls.
Diminished Physical Function
However, in multivariable analyses, the risk remained sta-
Several cross-sectional studies report an association be-
tistically significant only in men. The study was limited by
tween hyperkyphosis and poor physical function (3, 40,
its retrospective design (74). The association between hyper-
65 69). In an unadjusted analysis of 85 osteoporotic
kyphosis and fall risk warrants further investigation.
women age 50 to 82 years, those with hyperkyphosis re-
ported increased difficulties in bathing and washing (65). Increased Fractures
In another study of 98 postmenopausal women, those with Hyperkyphosis is associated with thoracic vertebral
curviscope-documented hyperkyphosis were more likely to fractures (14, 15, 18, 29). Many presume that fractures
report impaired physical mobility (66). lead to hyperkyphosis. However, with forward-bent pos-
Among studies of performance-based measures, one ture, changes in gravitational loads may increase fracture
involving women age 50 to 60 years found that, with in- risk through associations with gait instability and falls. In a
creasing flexicurve kyphosis, bench-press strength de- large prospective study (75), women with worse Debrun-
creased (r 0.32; P 0.05) and maximum oxygen ner kyphometermeasured kyphosis had more incident
uptake decreased (r 0.37; P 0.02) (39). In a study vertebral fractures. This effect seemed to be largely ac-
of 55 women, those with osteoporosis and vertebral frac- counted for by preexisting prevalent vertebral fracture, a
tures had greater Cobb angle kyphosis (median, 60) than known fracture risk factor (75). In another large prospec-
those with osteoporosis and no vertebral fractures (median, tive study (76), women with self-reported hyperkyphosis
43.5) or selected control patients (median, 37) (67). had a statistically significantly increased risk for future hip
They also had greater oxygen consumption and energy ex- fracture over 3 years (odds ratio, 3.3 [CI, 1.42 to 7.87];
penditure at rest than did those with osteoporosis without P 0.006). Although investigators adjusted for some po-
www.annals.org 4 September 2007 Annals of Internal Medicine Volume 147 Number 5 333
Review Hyperkyphosis in Older Persons

Figure 3. Postulated causes and consequences of hyperkyphosis in older persons.

Multifactorial Health Conditions Adverse Health Conditions

Vertebral fractures Worse pulmonary function


Muscle weakness Poor physical function
Disk height loss Falls Increased
Low bone density Hyperkyphosis Osteoporotic fractures Mortality
Ligament contraction Decreased quality of life
Physical inactivity Depression
Postural changes Functional dependence
Heritability

tential confounders in a multivariable analysis, they did not Increased Deaths


control for underlying vertebral fractures (76). In a case Some studies suggest associations between hyper-
control study, women with a history of wrist fracture had kyphosis and increased risk for death in older men and
greater thoracic kyphosis than did age-matched control pa- women (2, 5, 29, 92). One study reported that older
tients with no previous wrist, hip, or spine fractures (P women had an age-adjusted, 2.6-fold (CI, 1.3 to 5.1) in-
0.001) (77). Finally, in a study of 596 older women fol- creased risk for a pulmonary-related death with each 1-SD
lowed prospectively over 4 years, women with block- increase in kyphosis, but only 38% of those in the top
defined hyperkyphosis were at a 1.7-fold increased risk for quintile of kyphosis who died a pulmonary-related death
future fracture (CI, 1.0 to 2.97; P 0.049), independent had vertebral fractures (5). Two recent cohort studies con-
of age, bone mineral density, or previous fracture, com- firm that hyperkyphosis, independent of vertebral fractures
pared with those without hyperkyphosis (78). These find- and low bone mineral density, is associated with increased
ings suggest that hyperkyphosis may be associated with risk for deathin particular, with increased risk for pul-
increased fracture risk, independent of osteoporosis. monary death (2, 92).

Other Health-Related Consequences


MANAGEMENT OF HYPERKYPHOSIS
Age-related hyperkyphosis may be associated with
Standard therapies for age-related hyperkyphosis do
other adverse health effects. Two cross-sectional studies of
not yet exist. A plain spine radiograph can rule out under-
approximately 350 women reported that those with greater
lying osteoporotic vertebral fractures. The presence of frac-
kyphosis had increased odds of having pelvic prolapse (79, tures would justify the use of bisphosphonates or other
80). Case reports have also shown associations between osteoporosis therapy. Approximately 2 of 3 patients with
hyperkyphosis and insufficiency fractures of the sternum hyperkyphosis will not have a vertebral fracture. Those
(81 85) and dysphagia (86). without vertebral fractures should undergo bone density
testing. Low bone mineral density (T-score 2.5) would
justify starting osteoporosis therapy. We do not know
Impact on Quality of Life whether treating low bone mineral density can improve
Of studies that reported associations between hyper- hyperkyphosis, but analyses of data from a large random-
kyphosis and back pain, all but 1 reported statistically sig- ized clinical trial may soon help clarify whether bisphos-
nificant positive associations (15, 65, 8790). Another phonate therapy administration improves kyphosis (93).
study examined osteoporosis and quality of life and re- Nonsurgical Interventions
ported that after adjustment for age, patients with osteo- One randomized trial tested whether spinal orthosis
porosis and self-reported postural changes had increased improves trunk muscle strength, decreases the kyphosis an-
physical difficulty, made more adaptations in their daily gle, and improves quality of life in women with known
life, and had more fears about the future than did those vertebral fractures (94). The investigators reported statisti-
without osteoporosis (91). Demonstrating that the ill ef- cally significant improvement in all measured outcomes
fects of hyperkyphosis are not necessarily due to underlying and an 11% decrease in the kyphosis angle. Major limita-
fractures, women with postural changes and no osteoporo- tions included a small sample size (n 62) and no men-
sis had statistically significantly more physical difficulty tion of whether blinded outcome assessments were made.
and lifestyle adaptations than did those with a previous Another study evaluated the effect of back-strengthening
fracture and no postural changes. exercises on posture in 60 postmenopausal women and
334 4 September 2007 Annals of Internal Medicine Volume 147 Number 5 www.annals.org
Hyperkyphosis in Older Persons Review

reported no overall differences in either back strength or tutes of Healthfunded studies on hyperkyphosis are on-
kyphosis between the intervention and control groups. In a going. One study funded by the National Institutes of
post hoc analysis, women with substantial kyphosis and the HealthNational Institute on Aging prospectively follows
greatest increases in back-extensor strength demonstrated a 1000 women age 65 years or older over 15 years. It aims to
2.8-decrease in kyphosis angle (95). The exercise interven- document changes in thoracic kyphosis curvature, identify
tion was of reasonable duration (2 years), but the study was risk factors for worsening kyphosis, and determine the de-
small, nonblinded measurements were used, and positive gree of kyphosis that may be associated with adverse out-
findings were observed mostly in post hoc subgroup anal- comes (such as functional dependence) (28). Because the
yses. A third trial enrolled 12 women with hyperkyphosis dowagers hump also affects older men, similar studies of
(Cobb angle, 50 to 65; mean age, 77 years) and 13 fe- older men are needed. The second ongoing National Insti-
male control participants (mean age, 71 years). After a tutes of Healthfunded study is a randomized clinical trial
4-week intervention of wearing a spinal-weighted kypho- of a yoga intervention to increase spinal flexibility and de-
orthosis and using a specified back extension and gait pro- crease the kyphosis degree in older adults with hyper-
gram, women with hyperkyphosis demonstrated statisti- kyphosis (102). Results from the ongoing observational
cally significant improvement in balance and gait variables. studies and intervention trials should soon provide impor-
However, the control and intervention groups were of dis- tant information on modifiable risk factors for hyper-
parate ages and kyphosis improvement and control group kyphosis.
outcomes were not reported (96).
Two studies investigated whether spinal flexibility ex- CONCLUSION
ercises reduced hyperkyphosis in older persons (97, 98). A
In the words of Marcel Proust (103): The real voyage
randomized clinical trial of 210 older adults with impaired
of discovery consists not in seeking new landscapes but in
cardiorespiratory fitness that compared spinal flexibility
having new eyes. Hyperkyphosis is an easily recognized
plus aerobic training versus aerobic training only found no
and commonly observed postural change associated with
added benefit of the spinal flexibility training on physical
aging. Yet remarkably, todays physicians have little knowl-
functional outcomes or kyphosis angle (97). The other study
edge about its causes, consequences, or treatment to offer
was of a 3-month yoga intervention in older women with
affected patients. Because the existing overall body of per-
hyperkyphosis (n 21), in which participants demon-
tinent evidence is very limited, we believe that multidisci-
strated improved physical function without kyphosis im-
plinary research involving basic scientists, clinician re-
provement (98). While neither study demonstrated a ky-
searchers, and others is urgently needed to better delineate
phosis benefit, clinically significant hyperkyphosis probably
the causes of age-related hyperkyphosis, confirm and ex-
develops slowly over years. To be successful, an exercise
pand knowledge about its prognostic implications, and de-
intervention probably requires long-term implementation.
velop effective prevention and treatments.
Surgical Interventions
In the setting of painful vertebral fractures, vertebro- From the David Geffen School of Medicine at the University of Califor-
plasty and kyphoplasty are minimally invasive procedures nia, Los Angeles, Los Angeles, California.
that are gaining wider acceptance as effective treatments for
Acknowledgments: The authors thank Paul Mischel, MD, and Arun
intractable pain and possibly kyphosis. Several published
Karlamangla, PhD, MD, for their insightful comments and suggestions,
case series of both procedures and reviews of cases reported and John Ramirez, BA, for his help in preparing the manuscript for
reduced pain, improved physical function, vertebral height publication.
restoration of up to 90%, and kyphosis angle correction
ranging from 8.5 to 14 (99, 100). No published random- Grant Support: By the National Institutes of Health and National In-
ized, controlled trials, however, have evaluated or com- stitute on Aging (grants RO1 AG24246 and 1K12AG01004).
pared benefits and harms of the procedures.
More invasive surgical interventions for hyperkyphosis Potential Financial Conflicts of Interest: Consultancies: D.M. Kado
are associated with high rates of intra- and perioperative (Kyphon).
complications (33%). As such, they are generally reserved
Requests for Single Reprints: Deborah M. Kado, MD, MS, David
for patients with documented curve progression, intracta- Geffen School of Medicine at University of California, Los Angeles,
ble pain, or neurologic compromise (101). 10945 Le Conte Avenue, Suite 2339, Los Angeles, CA 90095; e-mail,
dkado@mednet.ucla.edu.
ONGOING RESEARCH Current author addresses are available at www.annals.org.
Most published studies of hyperkyphosis are cross-
sectional and include only a few participants, hampering
causal inference and generalizability. The eRA (Electronic References
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